State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Accessing Treatments — United States, 2018–2022

The prevalence of cigarette smoking among U.S. adults enrolled in Medicaid is higher than among adults with private insurance; more than one in five adults enrolled in Medicaid smokes cigarettes. Smoking cessation reduces the risk for smoking-related disease and death. Effective treatments for smoking cessation are available, and comprehensive, barrier-free insurance coverage of these treatments can increase cessation. However, Medicaid treatment coverage and treatment access barriers vary by state. The American Lung Association collected and analyzed state-level information regarding coverage for nine tobacco cessation treatments and seven access barriers for standard Medicaid enrollees. As of December 31, 2022, a total of 20 state Medicaid programs provided comprehensive coverage (all nine treatments), an increase from 15 as of December 31, 2018. Only three states had zero access barriers, an increase from two; all three also had comprehensive coverage. Although states continue to improve smoking cessation treatment coverage and decrease access barriers for standard Medicaid enrollees, coverage gaps and access barriers remain in many states. State Medicaid programs can improve the health of enrollees who smoke and potentially reduce health care expenditures by providing barrier-free coverage of all evidence-based cessation treatments and by promoting this coverage to enrollees and providers.


Introduction
Although the prevalence of cigarette smoking among U.S. adults has been declining for decades (reaching 11.5% in 2021), tobacco-related disparities persist among population groups (1).In 2021, smoking prevalence among adults enrolled in Medicaid (21.5%) was higher than it was among adults with private insurance (8.6%) (1).In addition, although interest in quitting and quit attempts are similar among adults enrolled in Medicaid and those with private insurance, successful cessation prevalence is lower among those enrolled in Medicaid (2).The high prevalence of smoking in this population not only contributes to a substantial health burden for this population but also to the cost of health care.Smoking-attributable health care spending was $225 billion in 2014, more than one half of which was paid by Medicare and Medicaid (3).
Effective treatments for smoking cessation include seven Food and Drug Administration (FDA)-approved medications* as well as individual, group, and telephone counseling (4).The U.S. Surgeon General has concluded that "insurance coverage for smoking cessation treatment that is comprehensive, barrierfree, and widely promoted increases the use of these treatment services, leads to higher rates of successful quitting, and is cost-effective" (4).Although states are required to provide Medicaid expansion † enrollees with coverage for all tobacco cessation treatments, § coverage for standard (i.e., traditional) Medicaid enrollees varies.Standard Medicaid enrollees are persons enrolled in Medicaid under traditional Medicaid eligibility criteria (e.g., low-income pregnant women, children, and persons with a disability), as opposed to Group XIII, or expansion, eligibility.Nationwide, approximately 80% of Medicaid enrollees are covered under standard Medicaid.¶ To assess cessation coverage policies among Medicaid programs, the American Lung Association collects state-level** information regarding coverage for nine tobacco cessation treatments † † and seven access barriers § § for standard Medicaid enrollees.Two states (Delaware and Utah), which had covered all seven medications for all standard enrollees in 2018, no longer did so as of 2022 (four medications in Delaware and two medications in Utah changed from being covered for all standard enrollees to being covered for only some standard enrollees).All 15 states that had provided comprehensive coverage as of December 2018 maintained that coverage through December 2022.Five states (Illinois, New York, North Dakota, Pennsylvania, and Virginia) added comprehensive coverage during the study period.

Treatment Access Barriers
During December 2018-December 2022, the number of states with a treatment access barrier decreased for all seven barriers.For example, the number of states not requiring copayments increased from 28 to 39.However, some barriers continue to be common.As of December 2022, the three most common barriers (that apply to all or some standard Medicaid enrollees) were duration limits (39 states; 76%), annual limits on the number of covered quit attempts (35; 69%), and requirement for prior authorization (30; 59%) (Table 3).These

Summary
What is already known about this topic?More than one in five adults enrolled in Medicaid smokes cigarettes.Comprehensive, barrier-free insurance coverage of tobacco cessation treatments can increase smoking cessation.

What is added by this report?
From 2018 to 2022, the number of states with comprehensive Medicaid coverage of tobacco cessation treatment increased from 15 to 20; states with no treatment access barriers increased from two to three.Coverage gaps and access barriers remain in many states.
What are the implications for public health practice?State Medicaid programs can improve the health of enrollees who smoke and potentially reduce health care expenditures by providing barrier-free coverage of all evidence-based tobacco cessation treatments and promoting this coverage to enrollees and providers.three barriers were also the most common in December 2018.As of December 2022, only three states (Kentucky, Missouri, and Wisconsin) provided barrier-free coverage, an increase from two (Kentucky and Missouri) in December 2018.All three of these states provided comprehensive coverage.

Discussion
During 2018-2022, states continued to add coverage of tobacco cessation treatments and to remove treatment access barriers for standard Medicaid enrollees.However, coverage gaps and access barriers remain in many states.Although the number of states with comprehensive coverage increased from 15 in 2018 to 20 in 2022, this increase falls short of the Healthy People 2030 target of all 50 states and DC.† † † In 2022, only three states provided coverage without any barriers.Increasing cessation coverage and decreasing barriers increases access to effective treatments that can increase the likelihood of successful quitting and improve health outcomes for persons who smoke (4).
The increase in the number of states with comprehensive treatment coverage and without barriers is likely related to state legislative actions.For example, Ohio passed legislation in 2020 requiring the state Medicaid program to cover a comprehensive cessation benefit with minimal barriers; Illinois passed similar legislation in 2021.§ § § These laws not only improve coverage and removed barriers, but also ensure that managed care plans will maintain this level of coverage in the future, even if new carriers are selected via competitive state bidding processes.
Laws like those passed in Ohio and Illinois can also help standardize tobacco cessation benefits across plans within a state.In the absence of such laws, treatment coverage and barriers can vary within a state's Medicaid program, potentially limiting treatment access.Different Medicaid-managed care plans within a state can set different coverage policies.Consistent comprehensive coverage of tobacco cessation treatments with minimal barriers has the potential to increase standard Medicaid enrollees' access to treatments and minimize confusion for both enrollees and providers.† † † https://health.gov/healthypeople/objectives-and-data/browse-objectives/tobacco-use/increase-medicaid-coverage-evidence-based-treatment-helppeople-quit-using-tobacco-tu-16 § § § https://www.legislature.ohio.gov/legislation/133/hb11;https://www.ilga.gov/legislation/BillStatus.asp?DocNum=2294&GAID=16&DocTypeID=S B&SessionID=110&GA=102 Improved cessation treatment coverage observed in this study might also be related to some states ¶ ¶ ¶ implementing Medicaid expansion during the study period (6).Many state Medicaid programs provide the same coverage for standard and expansion enrollees (7).Since states are required to provide expansion enrollees with coverage of all cessation treatments, consistency of coverage between standard and expansion plans might result in improvements in coverage for standard enrollees.Medicaid expansion has been shown to support cessation; states that have implemented Medicaid expansion have witnessed an increase in smoking cessation among lower-income adults (8,9).Opportunities remain for all states to improve coverage and increase promotion of available tobacco cessation benefits to encourage and support successful quitting.
This study demonstrates continued progress in decreasing tobacco cessation treatment access barriers for standard Medicaid enrollees.The biggest improvement in barrier removal was for copayments, with a nearly one third increase in the number of states without copayment requirements.One potential contributor to this change was enactment of the Families First Coronavirus Response Act (FFCRA),**** which increased the federal share of Medicaid spending by 6.2% with the requirement that states limit new cost-sharing for Medicaid enrollees.Continued monitoring of treatment access barriers remains important, particularly because the FFCRA maintenance of effort requirement, which limited cost-sharing, ended in 2023.† † † † How this change in policy might affect access barriers for cessation treatments is unknown.

Limitations
The findings in this report are subject to at least two limitations.First, Medicaid-managed care plans can change with little notice and can vary widely between plans, which can make determining up-to-date coverage challenging.Second, information provided by state personnel could not be verified, potentially resulting in data misclassification.

Implications for Public Health Practice
More than one in five adults enrolled in Medicaid smoke cigarettes (1).Increasing comprehensive, barrier-free tobacco cessation insurance coverage for the more than 48 million adults enrolled in Medicaid § § § § has the potential to reduce tobacco-related disparities in this population by increasing access to and usage of treatments that help persons quit smoking (4).By providing barrier-free coverage of all evidence-based tobacco cessation treatments, and promoting this coverage to enrollees and providers, state Medicaid programs can improve the health of enrollees who smoke and potentially reduce health care expenditures.

TABLE 1 . (Continued) Coverage of tobacco cessation counseling for standard Medicaid enrollees,* by state † -United States, 2018 § and 2022 ¶ State Coverage and year
* "Yes" indicates treatment is covered for all standard Medicaid enrollees; "No" indicates treatment is not covered for any standard Medicaid enrollee; "V" indicates treatment coverage varies, with treatment covered for some, but not all, standard Medicaid enrollees; and "P" indicates treatment is covered for pregnant women only.† Includes the District of Columbia.§ As of December 31, 2018.¶ As of December 31, 2022.

TABLE 3 . Barriers* to coverage for tobacco cessation treatments for standard Medicaid enrollees, † by state § -United States, 2018 ¶ and 2022** State Coverage barrier and year Copayments required
"Yes" indicates a barrier applies to all standard Medicaid enrollees; "No" indicates a barrier does not apply to any standard Medicaid enrollee; and "V" indicates a barrier applies to some, but not all, standard Medicaid enrollees.